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Weighing Physician Assistant Autonomy in Medical Practice


It hasn't been the easiest road to get to where I am today as a physician assistant, but things have definitely evolved for the better for our profession.

I have seen a significant evolution of the form and structure of physician/physician assistant teams in the 30-plus years that I have been a PA. Depending on the level of experience and the agreements set between PAs and their physician partners, PAs can be practice medicine with near autonomy, or have less experience and need more guidance than others.

For the most part, PAs have been employees of physicians, group practices, and sometimes, institutions. I have worked in each, yet my current position reflects the maturity and evolution of the PA profession in a way that follows the experience and example of our physician partners.

My California corporation is my sole employer, and the physician who is my practice partner is exactly that, my partner. I don't feel that I work for him, but with him. Being a surgical practice, we perform a lot of consults and surgeries each year. I bill directly for the work that I do, just like him, and take the risks, just like him. Doing emergency reconstructive surgery and taking calls for the ED, means that we perform a lot of surgery that never gets reimbursed along with the surgery we are compensated for.

It is difficult for PAs to be considered "independent contractors" under the current rules of the IRS, which is a complex issue and beyond the scope of this blog. I came to the conclusion after consulting counsel and reviewing the laws and regulations, and found that I had to go a different route to achieve more control over my professional life and career.

The level of supervision required of PAs, and the associated state laws, have evolved dramatically since I began practice in 1982 in California. It varies state-by-state, so it is important for physician / PA teams to know their local laws and requirements. Over the years, my physician team partners and I have developed a high level of trust and experience with each other that allows me a higher level of autonomy in the practice of medicine than say a new graduate.

Physician supervision is a fundamental aspect of the PA profession, and in fact, something that all PAs embrace. Yet the level of supervision is determined by state practice laws and by the practice itself.

It has been a difficult road at times because anytime you do something different in a traditional environment like the healthcare system, it presents challenges in that people in positions of authority don't know what to do with you or how to relate to you.

The other physicians with whom I work contract with my corporation for "PA services." I am considered a "leased employee" in the eyes of the law, and practices pay my corporation by the hour for my services. This allows them to treat me like an independent contractor, thereby avoiding a lot of employer-side employee costs like payroll taxes and workers' compensation. Physicians have been doing this for decades, and PAs are beginning to take advantage of these sorts of corporate structures in greater numbers, which I think is a win-win for everyone involved.

I have definitely run into some challenges with large California managed care companies. It took a long time to get a contract with one (even though they continued to pay my first assist services on a non-contract basis), and the argument they gave me went from: 1) we don't contract with non-physicians; to 2) how do we ensure that you are properly supervised as a PA?

I had to repeatedly remind the companies that how a PA is supervised (a legal and regulatory issue), is unrelated to how a PA is employed and paid. It took about a year. I was persistent, and it was beneficial to work for a specialty surgeon who was their only source of plastic and reconstructive surgery in our community. We became a "package deal," and I was grateful for his support. I became one of the first non-physicians to get a provider contract with their organization, and I'm sure now that others will follow as the healthcare system continues to evolve and mature in its recognition of PAs and other non-physician providers, incorporating and changing how they interface with the system.

I have to say that my situation has been very positive in achieving more control over my destiny as a professional. It has been also been positive, in my opinion, for the physicians with whom I practice, and has freed them from at least some of the hassles shared by employers in managing their human resources.

Physicians should be open to alternative relationships with PAs and others with whom they practice and everyone will benefit.

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